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3: Respiratory System

Approved: 4 Nov 2010. Last amended: 27 Sep 2023.

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3.1 Bronchodilators

Gloucestershire Asthma Guideline

Gloucestershire COPD Guideline

3.1.1 Adrenoceptor agonists

3.1.1.1 Short-acting beta2 agonists (SABAs)

Recommended

  • Easyhaler® Salbutamol DPI

    (salbutamol)

    • Alternative

  • Salbutamol MDI

    Prescribe a lower carbon footprint brand e.g. Salamol®

    • Specific Indication

  • Salbutamol

    nebules

    • 3.1.1.2 Long-Acting Beta2 Agonists (LABAs)

    Recommended

  • EasyHaler® Formoterol DPI

    (formoterol)

    • Alternative

  • Atimos Modulite® MDI

    (formoterol)

    • 3.1.2 Antimuscarinic bronchodilators

    3.1.2.1 Short-Acting Muscarinic Antagonists (SAMAs)

  • Ipratropium MDI
  • Ipratropium

    nebules

    • 3.1.2.2 Long-Acting Muscarinic Antagonists (LAMAs)

  • Incruse Ellipta® DPI

    (umeclidinium)

  • Spiriva Respimat® SMI

    (tiotropium)

    • 3.1.3 Theophylline

  • Theophylline (Uniphyllin®) m/r

    Oral

  • Aminophylline

    Parenteral

    • 3.1.4 Compound bronchodilator preparations

    Recommended

  • Anoro Ellipta® DPI

    (umeclidinium 55mcg / vilanterol 22mcg)

    • Alternative

  • Bevespi Aerosphere® MDI

    (glycopyrronium 7.2mcg / formoterol 5mcg)

  • Spiolto Respimat® MDI

    (tiotropium 2.5mcg / olodaterol 2.5mcg)

    • 3.1.5 Peak flow meters, inhaler devices and nebulisers

    3.1.5.1 Peak flow meters

  • Peak Flow Meter (standard and low range)

    • 3.1.5.2 Drug delivery devices - Spacers

    Spacers should be replaced every 12 months but some may need changing at six months.


    The spacer should be compatible with the MDI being used.


    Spacers should be cleaned monthly. Follow manufacturer's instructions.

  • Space Chamber Plus

    (one piece small volume spacer) – Compatible with most MDI devices

  • Aero Chamber Plus

    (one piece medium volume spacer) – Compatible with most MDI devices

  • Volumatic

    (two piece larger volume spacer) – Compatible with Clenil®, Flixotide®, Salamol®, Seretide®, Serevent®, Ventolin®

    • 3.1.5.3 Sodium Chloride for Nebulisation

    Recommended

  • Sodium chloride 0.9%

    • Specific Indication

  • Sodium chloride 7%

    Cystic Fibrosis. Specialist use only

    • 3.2 Corticosteroids

    3.2.1 General

  • Prednisolone (oral)

    Note: EC preparations are not recommended

  • Hydrocortisone (IV)

    when oral unsuitable

    • 3.2.2 Inhalers

    Gloucestershire Asthma Guideline

    Gloucestershire COPD Guideline

    Recommended

  • Easyhaler® Beclometasone DPI

    (beclometasone)

    • Alternative

  • Kelhale® MDI

    (beclometasone)

    Prescribe by brand name: Kelhale® contains ultrafine particles so is 2-2.5 times more potent than standard beclometasone containing inhalers at the same dose)

    • 3.2.3 Compound Preparations

    3.2.3.1 Asthma

    First choice formulary recommended inhalers for adults (≥18 years):

    Recommended

  • Fobumix Easyhaler® DPI

    (budesonide & formoterol)

  • Relvar Ellipta® DPI

    (fluticasone furoate & vilanterol)

  • Enerzair Breezhaler® DPI

    (indacaterol 114mcg / glycopyrronium 46mcg / mometasone 136mcg)

    • Alternative

  • Luforbec® MDI

    (beclometasone & formoterol)

    • 3.2.3.2 COPD

    Recommended

  • Trelegy Ellipta® DPI

    (fluticasone furoate, umeclidinium & vilanterol)

  • Trimbow® Nexthaler DPI

    (beclometasone, formoterol & glycopyrronium)

    • Alternative

  • Trimbow® MDI

    (beclometasone, formoterol & glycopyrronium)

  • Trixeo Aerosphere® MDI

    (formoterol 5mcg / budesonide 7.2mcg / glycopyrronium 160mcg)

    • 3.3 Cromoglicate, related therapy and leukotriene receptor antagonists, and phosphodiesterase type-4 inhibitors

    3.3.1 Cromoglicate and related therapy

  • None

    • 3.3.2 Leukotriene receptor antagonists

    Recommended

  • Montelukast

    • 3.3.3 Phosphodiesterase type-4 inhibitors

  • Roflumilast

    COPD, as per NICE TA461

    Shared Care Guideline

    • 3.4 Antihistamines, hyposensitisation, and allergic emergencies

    3.4.1 Antihistamines

    3.4.1.1 Non-sedating antihistamines

    Recommended

  • Loratadine
  • Cetirizine
  • Fexofenadine

    • Specific Indication

  • Rupatadine

    4th line for chronic idiopathic urticaria

    • 3.4.1.2 Sedating antihistamines

    Recommended

  • Chlorphenamine

    • Alternative

  • Hydroxyzine
  • Promethazine

    • 3.4.1.3 Allergen immunotherapy

    Specific Indication

  • Benralizumab

    NICE TA565

  • Dupilimab

    NICE TA751

  • Mepolizumab

    NICE TA671

  • Omalizumab

    NICE TA278, NICE TA339

  • Tezepelumab

    NICE TA880

  • Palforzia

    Peanut allergy NICE TA769

  • Reslizumab

    as per NICE TA479

  • Pharmalgen®

    as per NICE TA246

  • Grazax®

    Severe grass pollen allergy
    Shared Care Guideline

  • Acarizax®

    Severe house dust mite allergy

    • 3.4.2 Allergic emergencies

    3.4.2.1 Anaphylaxis

  • Adrenaline

    1 in 1,000: IM

  • Adrenaline (1 in 1,000) 150mcg and 300mcg Auto-Injector for self-administration IM

    Training for the specific auto-injector device must be given

  • Adrenaline

    1 in 10,000: slow IV injection reserved for severely ill patients where there is doubt about adequacy of the circulation and absorption from the IM site; with ECG monitoring.

  • Chlorphenamine

    slow IV injection

  • Hydrocortisone (sodium succinate)

    IV

    • 3.4.2.2 Angioedema

  • Berotralstat

    Prevention of recurrent attacks of hereditary angioedema, as per NICE TA738

  • C1-esterase inhibitor

    Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria

  • Conestat alfa

    Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria

  • Icatibant

    Acute attacks in hereditary angioedema. Specialist only, as per NHSE Criteria

  • Lanadelumab

    Prevention of recurrent attacks of hereditary angioedema, as per NICE TA606

    • 3.5 Respiratory stimulants and pulmonary surfactants

    3.5.1 Respiratory stimulants

  • Doxapram

    must be given under expert supervision and combined with active physiotherapy.

  • Mannitol (Osmohale®)

    bronchial provocation test.

    • 3.5.2 Pulmonary surfactants

  • None

    • 3.6 Oxygen

    See oxygen prescription chart and local guidelines

    3.7 Mucolytics

  • Carbocisteine

    Consider trial in COPD patients with chronic productive cough (as per NICE guidelines). Stop if no benefit within 4 weeks

  • Erdosteine

    Acute exacerbation of COPD. Respiratory Consultants only. Max 10 days.

  • Mannitol (Bronchitol®)

    dry powder for inhalation – Cystic Fibrosis as per NICE TA266

    • 3.7.1 Dornase alfa

  • Dornase alfa

    Cystic Fibrosis

    • 3.7.2 Mucous Clearing Devices

  • Acapella Choice®

    On the advice of a Respiratory Physiotherapist

  • Aerobika®

    On the advice of a Respiratory Physiotherapist

    • 3.8 Aromatic inhalations

  • None

    • 3.9 Cough preparations

    3.9.1 Cough suppressants

    Recommended

  • Pholcodine
  • Morphine

    cough in terminal disease

  • Methadone linctus

    Cough in terminal disease. Shared Care Guideline

    • 3.9.2 Demulcent and expectorant cough preparations

  • Simple linctus

    • 3.10 Systemic nasal decongestants

    Systemic nasal decongestants are classified in the BNF as being of limited therapeutic value

    3.11 Antifibrotics

  • Pirfenidone

    Idiopathic Pulmonary Fibrosis: NICE TA504

  • Nintedanib

    Idiopathic Pulmonary Fibrosis: NICE TA379

    • 3.12 Miscellaneous

  • N-acetylcysteine

    (oral) – Usual Interstitial Pneumonitis

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    Key

    Hospital / Specialist only

    Specialist initiated / advised (with Shared Care Guideline)

    Specialist initiated / advised (without Shared Care Guideline)

    Non-specialist or Specialist

    Treatment Guidelines

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